Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with significant physical and cognitive impairments. The resident, who had spastic hemiplegia and quadriplegia and was moderately cognitively impaired, complained of right ankle pain and was subsequently diagnosed with a closed fracture after being sent to the hospital. Documentation revealed that not all staff involved in the resident's care prior to the diagnosis were interviewed or asked to provide statements during the investigation. Interviews with staff who had direct knowledge of the resident's complaints of ankle pain prior to the diagnosis confirmed they were not included in the investigation process. Additionally, the resident reported that the injury occurred during a manual transfer performed by staff without proper assistance or equipment. The facility's investigation concluded that the most likely cause of the fracture was improper transfer by staff, but this could not be verified due to incomplete staff interviews and documentation.